Christine Gee: Balancing acts

IN my early days as a medical student, medicine seemed relatively black and white — either you got the exam question right, or you didn’t. Evidence seemed to show a clear basis for what to do and what not to do.

But in practice, there seems to be an increasingly delicate balance in delivering optimal patient care. Doctors would do well to be equipped with the poise of a Cirque du Soleil acrobat in order to tackle the increasingly precarious problems they face.

Blood pressure (BP) targets are a prime example. The old school of thought was the lower the BP the better (provided no dizziness or fainting resulted). But new research suggests that aggressively overshooting these targets can be just as dangerous as failing to reach them at all.

Data from two large US cohorts, one in patients with chronic kidney disease, suggest there is a fairly narrow window of optimally treated hypertension — too low, and the risk of mortality actually increases. In one of InSight’s news stories, local experts tell us these findings shed some doubt over current Australian BP recommendations.

Conflicting ethics and responsibilities in medical care create an even more challenging juggling act. The controversy around the treatment of asylum seekers in offshore detention centres is nothing new.

However, we are now hearing more from the doctors contracted to work in these centres and how they have struggled to balance their job responsibilities with their duty of care. MJA InSight columnist Jane McCredie speaks of the shame experienced by doctors faced with treating the patients who are often made ill by the very conditions under which they are detained.

Doctors dealing with end-of-life situations can also face challenging decisions. Advance care directives have become increasingly common but new research published by the MJA suggests that doctors’ knowledge of the applicable laws is suboptimal. As our lead news story explains, a practitioner acting on an ethical duty to deliver lifesaving care could find him or herself slapped with an assault charge if the patient’s legal rights have been misunderstood.

And what of doctors engaging in telemedicine? New technologies can revolutionise access to care for rural and remote patients but the standards of professional care in these settings remain poorly defined. In a Comment article for InSight, lawyer Bianca Phillips cautions doctors to seek specialist legal advice before participating in telemedicine, as despite the best intentions they may risk being found negligent.

Medical planners and policymakers also face increasing difficulties in balancing the allocation of resources. In another InSight news story this week we asked the experts whether Australia should follow the UK’s lead in adopting a centralised model of acute stroke care.

On the one hand, the UK experience suggests this might lead to impressive reductions in mortality. But would our substantially different geography provide barriers to accessing such care? Local experts agreed there is no obvious solution to this controversial problem.

Murky risk–benefit profiles also complicate decisions around preventive interventions, as research reported in our News in brief shows. Data suggest long-term aspirin therapy can have beneficial effects on cancer mortality, but it also carries a significant risk of fatal haemorrhage. Perhaps weighing up these outcomes by taking an individual’s risk profile into account can provide a solution.

Similarly, population prostate-specific antigen (PSA) screening continues to divide experts. Clearly, the potential reduction in prostate cancer mortality is desirable, but are the increased screening costs and associated morbidity too high a price to pay?

Finding balance in the face of uncertainty is not easy. Encouragingly, what is certain is that there is considerable ongoing research and effort to find resolution.

One of Einstein’s lesser known theories accords with this promise: “Life is like riding a bicycle. To keep your balance, you must keep moving”.

Dr Christine Gee is a deputy medical editor of the MJA and acting medical editor of MJA InSight. Dr Ruth Armstrong is on leave.